The findings of the complaint health survey (Intake # 25870) conducted 8/6/20 through 9/1/20 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
The sample was comprised of 7 current residents and 1 discharged resident. The facility had a census of 59 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint (Intake 25870) health survey conducted 10/09/20 through 10/12/20 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Based on interview and record review it was determined the facility failed to provide appropriate bathing services for 1 of 3 sampled residents (#11) reviewed for hygiene. This placed residents at risk for poor hygiene. Findings include:
Resident 11 admitted to the facility on 6/18/20 with diagnoses including a surgical wound from a BKA (below the knee amputation). The resident was cognitively intact.
The 6/18/20 care plan indicated Resident 11's bathing preference was to shower on Tuesday and Friday evenings.
The 6/25/20 Admission MDS Assessment indicated bathing did not occur during the seven day assessment period.
A review of the 6/2020 and 7/2020 Bathing Task Report revealed the following:
6/23 - Resident Refused
6/26 - Resident Refused
6/30 - Resident Refused
7/3 - Resident Refused
7/7 - Shower completed
7/10 - Resident Not Available
7/14 - Resident Refused
7/17 - Resident Refused
7/21 - Resident Refused
A review of the Clinical Alerts Listing Report from 6/18/20 through 7/22/20 revealed nursing staff reviewed and cleared alerts for "Resident Refused Shower/Bathing" seven times and for "No Bathing or Shower Documented in 7 Days on POC" five times.
A 6/29/20 Progress Note indicated the resident refused her/his shower and reported she/he would shower on 6/30 after her/his friend brought in clean clothes. There were no other progress notes related to the five other shower refusals.
On 8/11/20 at 11:25 AM Resident 11 reported she/he did not have any showers while at the facility. The resident reported one time staff informed her/him it was time for a shower, told her/him they would be right back and never returned. Resident 11 reported she/he used wash cloths and the sink to give her/himself sponge without assistance from staff.
On 8/17/20 at 2:06 PM Staff 13 (CNA) reported he could not recall the resident and was unable to provide information related to the shower refusals.
Attempts to speak with other CNA staff who documented shower refusals for Resident 11 were unsuccessful.
On 8/17/20 at 2:24 PM Staff 3 (RCM-LPN) stated he expected nurses to look into shower refusals and document their findings when they cleared an alert. He confirmed only one shower was documented for Resident 11 during her/his time at the facility.
Corrective Action(s) for residents identified to have been affectedResident # 11 no longer resides at facility.Identified of residents with the potential to be affectedAll current residents’ showers have been audited and any concerns addressed at that time.Measured to prevent recurrence:CNA’s and LN’s educated on shower documentation including refusals. RCM’s educated on the alert charting follow-up to include intervention.Monitor for Corrective Action:Nurse Managers will review the showers in MACC and will document any follow-up that is needed.DNS or designee will audit shower documentation weekly x4/weeks, then monthly for 2 months substantial compliance is met. Issues will be reviewed during the monthly QAPI meeting and a Performance Improvement Plan will be developed as necessary.
Based on interview and record review it was determined the facility failed to recognize the signs of an infection for 1 of 3 sampled residents (#11) reviewed for wound care. This placed residents at risk for infections. Findings include:
Resident 11 admitted to the facility in 6/2020 with diagnoses including a surgical wound from a BKA (below the knee amputation). The resident was cognitively intact.
A 6/18/20 Initial Wound Evaluation completed by Staff 4 (LPN) indicated the resident's wound measured 18 cm x 0.5 cm. There was no description of the type of tissue found in the wound bed. The surrounding skin was normal and there was no drainage or odor. The evaluation indicated the wound was to be cleaned with normal saline every other day, new dressing applied and wrapped with an ace bandage.
No orders or documentation related to the every other day wound care was found in the chart. The only order related to the BKA surgical wound was to monitor the dressing and reinforce as needed.
The 6/25/20 Weekly Wound Evaluation completed by Staff 4 indicated the wound measured 18 cm x 1 cm. The wound bed contained 25% slough (non-viable, yellow tissue). There was no documentation to indicate what the remaining 75% of the wound bed was comprised of. The surrounding skin was noted to be red and macerated (softened by drainage) with minimal watery drainage and a slight odor. Staff 4 determined the wound had deteriorated since the previous evaluation and notified the surgeon. Orders to perform daily wound care and dressing changes were obtained.
The 7/2/20 Weekly Wound Evaluation completed by Staff 4 indicated the wound measured 18 cm x 1.5 cm. The wound bed contained 25% slough and there was no documentation to indicate what the remaining 75% of the wound bed was comprised of. The surrounding skin was again noted to be red and macerated. There was no drainage or odor. Staff 4 determined the wound had improved since the previous evaluation.
The 7/9/20 Weekly Wound Evaluation completed by Staff 4 indicated the wound measured 17 cm x 2 cm. The wound bed contained 75% eschar (dry, black, hard dead tissue) and 25% granulation tissue (new tissue which indicates healing). The surrounding skin was normal with no drainage or odor. Staff 4 determined the wound had improved again since the previous evaluation.
The 7/16/20 Weekly Wound Evaluation completed by Staff 6 (RN) indicated the wound measured 17 cm x 2 cm. The wound bed contained 50% eschar, 25% slough and 25% granulation tissue. The surrounding skin was normal with no drainage or odor. Staff 6 determined there had been no change to the wound since the last evaluation.
A review of Resident 11's TAR revealed the daily wound care was completed daily as ordered with the exception of 7/8/20 and 7/22/20 when the resident had the dressing changed at a physician appointment and on 7/12/20 and 7/17/20 when the resident refused the dressing changes.
A 7/22/20 Patient Note from a surgeon follow up appointment revealed Resident 11's left BKA wound was healing poorly and there were concerns for an underlying infection. The resident was sent to the Emergency Department to prepare for wound debridement (the medical removal of dead, damaged or infected tissue).
The 7/22/20 Emergency Department Encounter note indicated Resident 11 presented with a BKA that "has been neglected and is very infected".
According to medical records from the hospital admission from 7/23/20 through 8/1/20 Resident 11's wound culture was positive for pseudomonas bacteria. The resident required surgical debridement of the wound under general anesthesia. During the resident's stay in the hospital she/he received daily doses of multiple IV antibiotics to treat the infection.
The TAR indicated Staff 6 regularly performed wound care for Resident 11 and was the last staff to view the wound with documented wound care completed on 7/18/20, 7/19/20, 7/19/20 and 7/21/20.
On 8/7/20 at 9:54 AM Staff 6 (RN) stated she performed the daily wound care for Resident 11 as documented on the TAR. She reported the resident's wound was healing poorly but had no signs of infection. Staff 6 verbalized knowledge of the signs and symptoms of infection.
On 8/7/20 at 10:14 AM Staff 4 (LPN) stated Resident 11's wound was healing poorly but did not believe it was infected. She verbalized knowledge of the signs and symptoms of infection.
On 8/10/20 at 3:40 PM Witness 1 (Complainant) reported when Resident 11 was seen in the surgeon's office on 7/22/20 the wound had a large amount of drainage, was boggy (an abnormal spongy texture usually due to high fluid content), incredibly painful and malodorous. She stated the resident informed her that facility staff had not changed the dressing for four days. Witness 1 reported wound cultures performed at the visit came back positive for pseudomonas (a type of bacteria) infection.
On 8/11/20 at 11:25 AM Resident 11 reported the facility staff frequently went three to four days without doing dressing changes to her/his wound.
On 8/17/20 at 9:36 AM Staff 10 (CNA) reported Resident 11 informed her that her/his left leg was painful and during the last week the resident was at the facility it seemed she/he was in more pain than usual. Staff 10 reported she informed nursing who administered pain medications. She stated she never visualized the wound as it was covered with a dressing.
On 8/17/20 at 9:45 AM Staff 17 (LPN) reported residents have informed her some nurses do not change their dressings when they were scheduled to.
On 8/17/20 at 11:05 AM Resident 12 reported she/he had difficulty having her/his wound care done on Fridays as scheduled. The resident reported the problem resolved recently.
On 8/17/20 at 12:00 PM Staff 16 (LPN) reported not all nurses performed wound care as they documented on the TAR.
The facility's 3/2020 Skin at Risk/Skin Breakdown policy and procedure indicated weekly wound rounds were to be completed by the DNS or designee and the RCM.
On 8/17/20 at 2:24 PM Staff 3 (RCM-LPN) stated he expected nursing staff to inform him if there was concerns for infection. He reported nursing staff informed him the resident's wound was not healing well but he was not told the wound was infected. Staff 3 stated he never assessed the wound.
Corrective Action(s) for residents identified to have been affectedResident # 11 no longer resides at facility.Identified of residents with the potential to be affectedAn audit of current residents with surgical wounds completed any concerns will be addressed at that time.Measured to prevent recurrence:LN’s educated on surgical wounds, dressings, change of conditions and notification of wound changes.Monitor for Corrective Action:RCMs or designee will audit surgical wounds for any changes or concerns weekly x4/weeks, then monthly for 2 months until substantial compliance is met. Audits will be brought through QAPI for review.
Based on observation, interview and record review it was determined the facility failed to identify and appropriately treat a medical device related pressure ulcer for 1 of 3 sampled residents (#13) reviewed for wounds. This placed residents at risk for worsening pressure ulcers. Findings include:
Resident 13 admitted to the facility in 12/2019 with diagnoses including abdominal hernia and osteomyelitis of the spine.
The facility's 3/2020 Skin at Risk/Skin Breakdown policy and procedure indicates the following:
If the new skin impairment is noted after admission, the licensed nurse should:
*Initiate Alert Charting.
*Complete a Braden Scale assessment if the new skin impairment is a pressure sore and evaluate current interventions for effectiveness.
*The RCM should complete a comprehensive review of the resident's medical record to evaluate if the pressure ulcer was avoidable or unavoidable.
A 5/27/20 Physician Note revealed Resident 13 developed an abdominal wound "likely secondary to pressure" from the thoracic brace.
Resident 13's comprehensive care plan revised on 6/9/20 revealed the resident had a potential for impairment to skin integrity related to the use of a thoracic back brace which caused friction. Interventions included "treatment to abdominal and include foam barrier against friction".
The 6/26/20 Quarterly MDS assessment indicated the resident had no wounds.
No documentation was found to indicate any assessments of the pressure ulcer were done. There was no documentation related to the stage of the pressure ulcer, size, tissue type, drainage, signs of infection or whether or not the wound had improved or worsened.
On 8/17/20 at 9:24 AM observation of Resident 13's abdominal wound revealed the wound was circular, approximately the size of a nickel, located on the hardened, herniated area of the right abdomen. The resident lifted and adjusted her/his back brace and showed how it rested at the location of the wound. There was no foam barrier noted as indicated in the care plan.
On 8/17/20 at 1:46 PM Staff 11 (LPN) stated Resident 13's abdominal wound was likely a pressure ulcer from where the brace rubbed on the area of her/his abdominal hernia. She reported a weekly skin assessment should have been initiated to document the wound weekly however it did not occur. Staff 11 reported initially foam was placed over the area to reduce friction but that was stopped sometime in June.
Staff 3 (RCM-LPN) stated he believed Resident 13's wound was an abrasion and was not aware it was a pressure ulcer. He stated he expected the floor nurses to handle wound care for residents and inform him if there was a concern. Staff 3 confirmed there was no regular assessment completed of the wound to monitor the measurements, drainage, symptoms of infection or if it improved or worsened. Staff 3 reported he was unaware the wound was related to pressure from the brace. He reported if he had known it was a pressure wound it would have been treated differently; monitored weekly by the RCM as well as an outside wound care nurse.
Corrective Action(s) for residents identified to have been affectedResident #13 was evaluated by the United Wound Healing Team and Care plan updated as appropriate.Identified of residents with the potential to be affectedAn audit of current residents with wounds including abrasion and skin tears evaluated for appropriate classification any concerns addressed at that time. An audit of resident with wounds care plan completed any concerns addressed at that time.Measured to prevent recurrence:LN’s educated on classification of wounds, following orders and care plan interventions.Monitor for Corrective Action:RCMs or designee will audit wounds and care plans for any changes or concerns weekly x4/weeks, then monthly for 2 months until substantial compliance is met. Audits will be brought through QAPI for review.
Based on interview and record review the facility failed to address the nutritional needs of residents with a poor healing surgical wound and pressure ulcer for 2 of 3 (#11 and #13) sampled residents reviewed for nutrition. This placed residents at risk for poor nutrition and wound healing. Findings include:
1. Resident 11 admitted to the facility in 6/2020 with diagnoses including a surgical wound from a BKA (below the knee amputation) and diabetes. The resident was cognitively intact.
The facility's 3/2020 Skin at Risk/Skin Breakdown policy and procedure indicates the Registered Dietitian should be notified of a worsening wound condition for a nutritional needs assessment.
The 6/25/20 Admission MDS Assessment indicated the resident would be seen in the Nutrition at Risk (NAR) meetings related to her/his surgical wound.
A 6/25/20 Wound Evaluation indicated Resident 11's surgical wound had deteriorated.
A 7/9/20 NAR note indicated the resident was discussed in the NAR meeting related to weight gain. The plan was to reweigh the resident. While it was documented the resident had a surgical wound, there was no documentation related to the deterioration and poor healing of the wound.
A review of the resident's weights documented in 6/2020 and 7/2020 revealed there was an error in the documentation and there was no weight gain.
On 8/7/20 at 9:54 AM Staff 6 (RN) reported Resident 11's wound was not healing well.
On 8/7/20 at 10:14 AM Staff 4 (LPN) reported the resident's surgical wound had broken down, did not look healthy and was not healing well.
On 8/17/20 at 2:24 PM Staff 3 (RCM-LPN) reported he knew Resident 11's wound was healing poorly. Staff 3 reported the resident should have been followed on NAR for her/his surgical wound.
2. Resident 13 admitted to the facility in 12/2019 with diagnoses including abdominal hernia and osteomyelitis of the spine.
The National Pressure injury Advisory Panel 2019 International Clinical Practice Guideline indicates quality nutrition comprised of adequate calories, protein, vitamins and minerals promotes pressure ulcer healing. The document points to fortified foods and nutritional supplements as an intervention for pressure injuries.
The facility's 3/2020 Skin at Risk/Skin Breakdown policy and procedure indicates the Registered Dietitian should be notified of new pressure sores for a nutritional needs assessment.
A 5/27/20 Physician Note revealed Resident 13 developed an abdominal wound "likely secondary to pressure" from the thoracic brace.
Nutrition at Risk notes revealed Resident 13 was discussed with the Registered Dietitian on 7/3/20, 7/30/20 and 8/13/20 due to weight gain. There was no documentation related to the pressure ulcer. Resident 13's portion sizes were reduced for all meals. There was no consideration given to the increased nutritional needs to promote wound healing.
On 8/17/20 at 2:24 PM Staff 3 (RCM-LPN) reported residents with pressure ulcers are reviewed monthly in the Nutrition at Risk meetings with the Registered Dietitian. He stated he did not have the Registered Dietitian perform a nutritional needs assessment related to wound healing for Resident 13 because he was not aware she/he had a pressure ulcer.
Corrective Action(s) for residents identified to have been affectedResident # 11 no longer resides at facility.Identified of residents with the potential to be affectedAn audit of current residents with surgical wounds completed any concerns will be addressed at that time.Measured to prevent recurrence:DNS and RCM’s educated on Nutrition Risk Review Policy and Procedure.Monitor for Corrective Action:DNS or designee will audit NAR notes for residents with surgical wounds for appropriate documentation and follow-up weekly x4/weeks, then monthly thereafter for 2 months until substantial compliance is met. Audit will be brought through QAPI for review.
The findings of the state complaint survey (Intake #25870) conducted 8/6/20 through 9/1/20 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 9/1/20.
The sample was comprised of 7 current residents and 1 closed records. The facility had a census of 59 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint (Intake 25870) health survey conducted 10/09/20 through 10/12/20 are documented in this report. The facility was found to be in substantial compliance with OAR 411-85 through 89.
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OAR 411-086-0100 Nursing Services: Resident Care
Refer to F676, F684
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F686, F692
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